GW1-2022-03789_Well Construction - GW1_20220404

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I.Well Contractor Information:
Adt Fr'ill 14:.WATER ZONES;'.
Well Contractor Name FROM TO I DESCRIPTION r
72 ' A ox
ft ft
ft ft �
NC Well Contractor Certification Number
15.OUTER CASING,(for multi=rasea*tills)091UNER(if'a"
Morgan Well &Pump, Inc. : FROM To''/ DIAMETER' THICMNESS MATERIAL
Corn an Name +1 ft. vy7y ft 61/81 i . i
in• sd21 pvc
P Y
t r7 16.-Di DER CASING OR•TIIBIIVG''eot]ieiiaal-ci6•seCL-166
2.Well Construction Permit# FROM TO I DIAMETIM I THICKNESS MATERIAL
List all applicable well constructionpermits'r e.UIC,County,State,Variance,eta)• ft• ft in.
3.Well Use(check well use): ft• ft in.
17_-SCREEN'.:
Water Supply Well: FROM I TO DIAMETER SLOT SIZE TFirCKMS I~MATERIAL.
Agricultural 'ii Municipal/Public ft ft-
Geothermal
(Heating/Cooling Supply) sideniial Water Supply(single) ft ft
I IndusiriaUCommercial Residential Water Supply(shared) i8:GRODT•::.
Iui ation FROM TO MATERIAL - 3%2L.4CEMENTI4IETHOD&.4MOUNT
Non-Water Supply Well: o ft- 20 ft bentanite poured
'Monitoring .Recovery ft. ft.
Injection Well: ft. ft.
_i Aquifer Recharge [3GroundwaterRemediatien r.
::19:SAND/GRAVEL'PACK if a: "licabre
Aquifer Storage and Recovery OSalinityBarrier FROM TO MATERIAL. EMPLACEMENTi=OD''
Aquifer Test nStormwater Drainage- ft. ft
Experimental Technology Subsidence Control ft ft.
i Geothermal(Closed Loop) OITracer :ZO.tiR1LLIl�G.LOG'(attacti`addition'sl slieets ifnecessa')':: :•:;i. --
I Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM To DESCRIPTION.(color,hardness,sail/rack type grain size efe)
ft
4.Date Well(s)Completed: . Well ID# ft
Sa.Well Location: [� lot ft f. s(�
ft.
Facility/Owner
Name P
Facility.ID#(iapplicable)�) ft
ft ft
e- ;�Physical Address,City,and Zip ft. ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: APR
(if well field,one lat/long is sufficient) 22.Certification:
6 cI "7
6.Is(are)the well an s) Perment or TempoZNo
Signature of Cert' a ell Contractor Date
By signing this form,I m hereby ter that the well(s)was(were)constructed in accordance "
7.Is this a repair to an existing well: n'Yes or with ISA NCAC 02C.0100 or 15A NCAC 02C•.0200 Well Construction Standards and that a
Ifthis is a repair fill out known well construction iriformation and explain the nature ofthe copy ofthis record has beer:provided to the ivell owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
contraction,only 1 GW-1 is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled: " SUBMITTAL INSTRUCTIONS
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9.Total well depth below Land surface: 9. __3 (ft.) 24a. For All Wells: Submit this foivr within 30 days of completion of well
For multiple wells list all depths ifd�erent(example-3@,�200'a»d 2@100) construction to the following
10.Static water level below top of casing: 70 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.} 24b.For Iniection Wells: In addition to;sending the form to the address in 24a
I above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: LI construction to the following:
(Le.auger,rotary,cable,directpush,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS-ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) LIS Method of test: air pressure 24c.For Water SuuDly&Iniection Wells: In addition to sending the form to
fJ
the address(es) 'above, also submit one 6opy of this form within 30 days of
13b.Disinfection type: d• Amount: 6&7 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmentat Quality-Division of Water Resources i Revised 2-22-2016
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